Self completion medical history form -

Pregnancy
Please complete this form to the best of your ability. If you do not understand or prefer not to answer any question,
leave it blank. You will have a chance to talk about the answers with a doctor or nurse during your visit.

First name: Surname:

Today’s date (dd/mm/yy): Date of birth (dd/mm/yy): Your age:

If you answer yes to any questions, we will discuss the details with you. If you are unsure of a question, please leave it blank.

Allergies This column is for bpas staff

Are you allergic to latex Yes No

Are you allergic to any medicines? Yes No

Are you allergic to anything else? Yes No

If yes, what?

Menstrual history

What was the first day of your last

menstrual period? (dd/mm/yy)

Don’t know

Are you sure of that date? Yes No N/A

How many days does your period last? days

How many days are there between your periods? days

Are your periods regular? Yes No N/A

Pregnancy history
How many times have you been
pregnant in total (including this one)?

Deliveries
Year Length of Delivery type Problems
pregnancy (if any)
(weeks or Vaginal C-section
months)

continued overleaf 1
Miscarriage, abortion, and ectopic This column is for bpas staff

Year Length of Miscarriage Abortion Ectopic Problems

pregnancy (if any)
(weeks or
months)

Have you had an ultrasound scan during Yes No

your current pregnancy? If yes, please bring copy to your appointment

Have you had any pain during your

current pregnancy? Yes No

Have you had any bleeding during

your current pregnancy? Yes No

Have you had any nausea or vomiting

during your current pregnancy? Yes No

Are you currently breastfeeding? Yes No

Surgical history

Have you ever had any operations? Yes No

Year Type of operation Problems

(if any)

Have you ever had a general anaesthetic Yes No

(been put to sleep for surgery)?

Have you or anyone in your immediate

family ever had any problems with any Yes No N/A
anaesthetic?

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Medical history

Do you use any prescription medicines? Yes No This column is for bpas staff
If yes, please bring them with you

Do you use any other medicines such as Yes No

herbal or homeopathic rememdies? If yes, please bring them with you

Do you have, or have you ever had any of the following:

Asthma Yes No

Other breathing problems Yes No

High blood pressure Yes No

Heart disease Yes No

Heart valve problems Yes No

Heart attack Yes No

Stroke Yes No

Migraine headaches Yes No

Blood clots in your legs, arms or lungs (DVT) Yes No

Bleeding disorder (like haemophilia) Yes No

Clotting disorder (like Factor V Leiden) Yes No

Anaemia Yes No

Sickle cell disease Yes No

Thalassaemia Yes No

Seizures/fits/epilepsy Yes No

Brain tumours Yes No

Mental health problems Yes No

Adrenal problems Yes No

Liver problems Yes No

Gallbladder problems Yes No

Any other gastrointestinal problem Yes No

(like ulcers or irritable bowel syndrome)

Thyroid problems Yes No

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Do you have, or have you ever had, any of the following: This column is for bpas staff

Breast cancer Yes No

Cancer of any kind Yes No

What was the date of your last cervical smear?

Abnormal cervical smear Yes No

Treatment to your cervix (neck of the womb) Yes No

Uterine fibroids Yes No

Abnormally shaped uterus Yes No

Pelvic infection Yes No

Sexually transmitted infection Yes No

Hepatitis Yes No

HIV/AIDS Yes No

Have you ever been told you are at

increased risk of CJD or vCJD for Yes No
public health purposes?

Do you have any other medical problems

not mentioned here? Yes No

Social history

Do you smoke tobacco? Yes No

Do you use any recreational drugs? Yes No

Contraception history

Were you using any contraception at

the time that you got pregnant with Yes No
your current pregnancy?
If yes, what were you using?

Do you have a copper coil (IUD) or

Mirena coil (IUS) currently in place? Yes No

To the best of my knowledge, the information I have provided is correct and complete.
Signature Date

Thank you for completing this form

PRI-CON-529 4